How can frontline expertise and new models of care best contribute to safely reducing avoidable acute admissions? A mixed-methods study of four acute hospitals

Abstract

BackgroundHospital emergency admissions have risen annually, exacerbating pressures on emergency departments (EDs) and acute medical units. These pressures have an adverse impact on patient experience and potentially lead to suboptimal clinical decision-making. In response, a variety of innovations have been developed, but whether or not these reduce inappropriate admissions or improve patient and clinician experience is largely unknown.AimsTo investigate the interplay of service factors influencing decision-making about emergency admissions, and to understand how the medical assessment process is experienced by patients, carers and practitioners.MethodsThe project used a multiple case study design for a mixed-methods analysis of decision-making about admissions in four acute hospitals. The primary research comprised two parts: value stream mapping to measure time spent by practitioners on key activities in 108 patient pathways, including an embedded study of cost; and an ethnographic study incorporating data from 65 patients, 30 carers and 282 practitioners of different specialties and levels. Additional data were collected through a clinical panel, learning sets, stakeholder workshops, reading groups and review of site data and documentation. We used a realist synthesis approach to integrate findings from all sources.FindingsPatients’ experiences of emergency care were positive and they often did not raise concerns, whereas carers were more vocal. Staff’s focus on patient flow sometimes limited time for basic care, optimal communication and shared decision-making. Practitioners admitted or discharged few patients during the first hour, but decision-making increased rapidly towards the 4-hour target. Overall, patients’ journey times were similar, although waiting before being seen, for tests or after admission decisions, varied considerably. The meaning of what constituted an ‘admission’ varied across sites and sometimes within a site. Medical and social complexity, targets and ‘bed pressure’, patient safety and risk, each influenced admission/discharge decision-making. Each site responded to these pressures with different initiatives designed to expedite appropriate decision-making. New ways of using hospital ‘space’ were identified. Clinical decision units and observation wards allow potentially dischargeable patients with medical and/or social complexity to be ‘off the clock’, allowing time for tests, observation or safe discharge. New teams supported admission avoidance: an acute general practitioner service filtered patients prior to arrival; discharge teams linked with community services; specialist teams for the elderly facilitated outpatient treatment. Senior doctors had a range of roles: evaluating complex patients, advising and training juniors, and overseeing ED activity.ConclusionsThis research shows how hospitals under pressure manage complexity, safety and risk in emergency care by developing ‘ground-up’ initiatives that facilitate timely, appropriate and safe decision-making, and alternative care pathways for lower-risk, ambulatory patients. New teams and ‘off the clock’ spaces contribute to safely reducing avoidable admissions; frontline expertise brings value not only by placing senior experienced practitioners at the front door of EDs, but also by using seniors in advisory roles. Although the principal limitation of this research is its observational design, so that causation cannot be inferred, its strength is hypothesis generation. Further research should test whether or not the service and care innovations identified here can improve patient experience of acute care and safely reduce avoidable admissions.FundingThe National Institute for Health Research (NIHR) Health Services and Delivery Research programme (project number 10/1010/06). This research was supported by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula.

Exploring emergency department 4-hour target performance and cancelled elective operations: a regression analysis of routinely collected and openly reported NHS trust data

“…By comparison, another multivariate model could predict only 6.8% variation in 4-hour target (using patient demographics and satisfaction with general practitioner (GP) service rates). 22 There are a number of factors that may affect ED processes and performance measures: macrohospital or intrahospital flow (ie, patient flows across the whole trust, such as those investigated in this study); microflow factors within departments/wards (ie, staffing, 4 17 work flows, 26 31 access to diagnostics 17 ); population factors (ie, age, sex, deprivation, 22 32 access to GP/community/social care services 22 33 ); noise (ie, recording errors, reporting differences, 10 ‘gaming’ of 4-hour target 5 17 ). If the mechanisms of pressures facing acute trusts are to be understood more fully, future work is required to quantify the relative effects of each of these factors on trust performance measures.…”

“… 36 Our results show that ED conversion ratio was important in explaining some variation in 4-hour performance and cancelled elective operations; however, conversion ratios of trusts in England have not changed noticeably between 2012 and 2016 (see table 2 ) while some trusts are already known to have introduced clinical streaming. 17 It is currently unclear if there would be significant changes to trust conversion ratios with the proposed roll-out of clinical streaming 6 by NHS England. More research is needed to understand if clinical streaming impacts on patient flow in a positive manner.…”

“…The efficiency of internal ED microflow has been analysed extensively using modelling and simulation. 23–25 This, for example, has explored the use of fast tracks for minor injuries or patient ‘streaming’ (now commonplace in England), 26 prioritisation by acuity, 17 and workforce scheduling and resourcing. 27 Processes of patient flow through ED and into trusts have also been shown to vary considerably between sites.…”

“… 27 Processes of patient flow through ED and into trusts have also been shown to vary considerably between sites. 17 However, our unit of analysis is the hospital and its effects on 4-hour performance.…”

The questioning lens as research tool: the social shaping of network visualisation boundaries in the case of the UK junior doctors’ contract dispute

“…Following the principles of this framework (see Seinet al, 2011) we captured the actions that disrupted users' processes or understanding (McCurby, Dykes, & Meyer, 2016). The authors began to discuss public perception and the role of the media while researching NHS provision and avoidable admissions into Accident and Emergency (Pinkney et al, 2016), forming the first stage of ADR, 'problem formulation, grounding design in theory and real-world problems'. These discussions led to the research aim to explore the role of mainstream media and the use of social media in medical settings; such as the increasing coverage of the U.K. junior doctors' contract debate on Twitter.…”